Primary care physicians (PCPs) have a group of patients who are difficult to treat effectively, namely patients with low back pain (LBP). These patients have high expectations for pain relief and want immediate results. These patients vary in size, weight, and age, and have complex causes of pain and varying lesions. Low back pain is only a symptom and the cause and associated lesions may not be identified. Because back pain can severely limit a patient’s mobility, patients often experience a very strong sense of loss when the pain is not relieved or is expected to take a long time to resolve. LBP is the fifth most common cause of back pain among patients presenting to PCP. Therefore, PCPs will spend a lot of time with patients with LBP. Of all the structures in the human body, the spine seems to be experiencing particular problems. Although the spine primarily serves as a scaffold for the body, keeping it upright, this does not mean that he is able to support the obese body of the modern patient or accommodate the physiological need to lift heavy objects or overuse it (in cases where the back muscles are not strong enough). Causes of LBP Low back pain may be caused by skeletal muscle tension, while the latter may be caused by strain and spinal lesions due to aging, infection or malignancy. Patients at risk for LBP are: those with poor physiological status and unable to participate in regular physical activity; those older than 55 years of age; workers who have been involved in heavy physical labor for a significant period of time (e.g., construction workers); those who are obese; those with narrowed spinal canal and spinal stenosis; those who smoke or use drugs; and those with low socioeconomic status. There are a number of warning signs that must be heeded when evaluating a patient with LBP. Malignancy may be the cause of pain if the patient has lost significant weight or complains of pain that worsens at night and does not resolve at rest in a flat position. Neurological symptoms such as sudden onset of incontinence or worsening foot drop may indicate spinal cord injury or progression of neurological disease. Another alarming sign is severe or progressive neurological dysfunction and weakness of important muscles in the lower extremities. Other causes of LBP are kidney or urinary tract infections, and gynecological conditions such as ovarian cysts can also cause low back pain. Evaluation When LBP is acute, most physicians are fairly confident in the pain diagnosis. However, when the pain becomes chronic, the physician may feel that the patient is all presenting the same, regardless of the level of pain. Patients with chronic pain have learned to cope with the pain and often appear to be pain free, making the identification of pain level difficult. In addition, patients with chronic LBP may have vague or multi-site complaints, and it may be difficult to identify the site of pain. Constantly talking about their pain with family and friends may strain their relationship with each other, and chronic pain patients learn when and to whom they can let go of talking about their pain. In performing a basic pain assessment, we must ask the patient the following questions: the patient’s pain intensity level as determined by a validated pain rating scale (0 to 1010 numbered scale) and all changes in pain when the patient is active or moving; the area of pain and all areas where the pain radiates; the duration of the pain and any events that may have caused the pain, such as lifting heavy objects; the The nature of the pain (e.g., sharp, dull, or shooting pain). Any functional impairment such as inability to walk up and down stairs, pain that interferes with sleep, eating, social relationships, etc. Chronic pain is difficult to manage and control. When pain persists without relief, patients often report an inability to concentrate, sleep well, participate in hobby activities, help with household chores, or participate in physical activity and work. Chronic pain can have a significant impact on the patient and their family. Patients often feel crazy and irritable, unable to manage things well, feel worthless and depressed. Treatment options The treatment options for acute LBP are fairly simple and straightforward. The current recommendations are: Stay active. There is no indication for bed rest in acute LBP. Staying as active as possible may promote recovery and maintain function. If the patient has a clear indication and no history of cardiovascular disease or gastrointestinal bleeding, a short course of nonsteroidal anti-inflammatory drugs (NSAIDs ), i.e., nonselective anti-inflammatory drugs (e.g., ibuprofen or naproxen) or COX-2 inhibitors (celecoxib), may be useful for acute back pain. When using these medications, use them for the shortest possible time, use the lowest effective dose possible, and try to use them in patients who do have a clear indication and low risk factors; give the patient medications appropriate to the patient’s reported pain level; and try heat therapy, cold packs, pain creams, or massage, if the patient is willing to accept these therapies. Chronic LBP is a complex condition to treat because it is persistent and symptomatic on a daily basis. Many patients with chronic LBP have a physical injury, but the injury does not progress. In treating these patients, we must use a multidisciplinary approach. Patients with injuries can benefit from receiving physical therapy programs that focus on improving motor skills; NSAIDs do not make a difference in chronic LBP. These drugs can be beneficial when used for a short period of time in acute LBP at the lowest possible dose. The inflammatory response in those with chronic LBP differs from that in those with acute LBP. Acute injuries produce swelling and an inflammatory response. When the pain becomes chronic, the body has adapted and the inflammatory response has disappeared and stopped. Only the soft tissue injury or spinal injury persists, causing the patient motor impairment and persistent pain. Many patients with chronic LBP continue to take opioids, but addiction does not occur. When a patient takes an opioid daily for pain relief, the patient is considered drug dependent. Addiction is a chronic neurobiological disorder in which a patient abuses prescription pain medications or uses addictive drugs. Addicts cannot control their own drug choices. On the other hand, chronic pain patients are constantly searching for pain relief and using opioid prescription drugs under the guidance of a prescribing physician to improve their functioning. The physician must distinguish between opioid dependence and addiction. Add sleep-promoting and antidepressant medications such as selective 5-hydroxytryptamine norepinephrine reuptake inhibitors (SSNRIs), selective reuptake inhibitors (SSRIs), or tricyclic antidepressants (TCAs). Referral of patients to treatment programs that help patients build coping skills and positive images Use non-pharmacologic interventions such as heat therapy, cold compresses, acupuncture, or pain creams if the patient is interested. Consider referring the patient to a pain intervention clinic to be evaluated for direct epidural corticosteroid injections at the site of disc compression of the nerve root. If the patient is suitable for treatment with this therapy, the pain therapist may perform 3 consecutive injections, and this treatment may significantly reduce the patient’s pain. Pharmacologic treatment of chronic LBP The World Health Organization (WHO) three-step approach to pain relief was first developed for cancer pain treatment, but is now commonly used for the treatment of all types of pain. The choice of pain medication should be based on the patient’s pain level. Patients with chronic pain that requires pain relief for more than 24 hours can use extended-release pain medications. Medication tips Correct selection of medication appropriate for the pain complaint. Limit acetaminophen to a maximum dosage of 4000 mg/d (for patients without organ dysfunction). The dose should be reduced in patients who consume alcohol regularly or have organ dysfunction. Proposed opioids Mild pain-pain intensity1 to 3 Dexpropoxyphene: contains acetaminophen 650 mg/tablet. Monitor total daily acetaminophen intake (particularly harmful for those aged >60 years) Moderate pain-pain intensity 4 to 6 Acetaminophen-codeine: at higher doses may be considered a moderate intensity pain reliever; oxycodone-acetaminophen; oxycodone-aspirin; controlled-release oxycodone (OxyContin) Severe pain-pain intensity 7 to 10 High-dose controlled-release oxycodone; immediate-release morphine; controlled-release morphine; oxy morphine ketone; fentanyl patch.